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Building on a previous post where I mentioned that Plantar Fasciitis should more accurately be referred to as “Plantar Fasciosis“, we’re revisiting that discussion in more depth. It’s important to understand the physiological differences in these conditions, because it helps us to provide more effective treatment. More appropriate treatment means faster recovery with less chance of re-injury.
Did You Know?
The majority of cases of tennis elbow (lateral epicondylitis), plantar fasciitis and bicipital tendinitis are not related to inflammation at all? Their names really should most commonly be “lateral epicondylosis, plantar fasciosis and bicipital tendinosis respectively.
The alteration of tendinitis to tendinosis is relatively small, yet significant. Any time you see the suffix “itis”, it refers to inflammation. Any time you see “osis”, it’s talking about pathological state, not necessarily related to inflammation.
How Do We Know The Difference?
Tendinitis
~ is only the appropriate diagnosis when an injury to the tendon is acute. This means you would have to overload the fibers of the tendon with either too much weight in total, or too quickly load the tendon.
Tendinosis
~ on the other hand is due to the repeated overuse of the tendon, without sufficient time to heal. We typically refer to these as “repetitive strain injuries”, and they form over time. Even small weights and small movements, done too frequently can result in tendinosis. Collagen fibers in the tendon become disorganized, discontinuous and they can even change type (there are many different types of collagen). These changes cause weakness of the tendon, degeneration and pain. In multiple microscopic examinations, there have not been any inflammatory factors present in these types of injuries, making it incorrect to call it “tendinitis”. (reference).
So What Does This Mean For Getting Out Of Pain?
Firstly we have to understand what is causing the pain. In the case of tendinitis we most commonly experience pain as a result of inflammatory markers interacting with the nervous system to stimulate pain receptors. In the case of tendinosis the pain instead comes (most likely) from the physical disruption of the fibers instead of the local chemical environment.
Each condition focuses on different treatment outcomes and protocols. For example, a common treatment plan for tendinitis revolves around reducing inflammation initially. Not only is it not helpful to do this for tendinosis (because there is essentially no inflammation present), it can also do greater damage! Certain corticosteriods and non-steroidal anti-inflammatory drugs have actually been shown to inhibit collagen production/repair.
Another major difference in the treatment of these conditions is the length of time they may take to heal. Typically you can expect to resolve inflammatory conditions (tendinitis) within about 6-weeks given the appropriate treatment (and if you do your homework!). On the other hand, tendinosis can take much longer – sometimes between 6 to 9 months, once it has become chronic.
How Can Massage Help?
Deep frictions have been shown to be beneficial in both scenarios (tendinitis and tendinosis), but for different reasons.
Tendinitis
Frictions in this instance help to reduce adhesions and improve the alignment of the collagen fibers as they form a scar. This helps to improve the function of the tendon once healed. We have to be attentive to how much work we do in this circumstance – we want to encourage blood flow, but to just the right amount. And of course, we don’t treat within the first 72 hours.
Tendinosis
Deep frictions for tendinosis actually help to stimulate fibroblast activity, which are the cells responsible for producing collagen. This means greater repair and regeneration of tissue that has degenerated.
Deep frictions don’t necessarily have to be painful! And in fact, you should avoid going that hard. For a great guide on administering these massage frictions yourself (safely and effectively), take a look here at: painscience.com.
Have you ever been diagnosed with tendinits when it should have been more appropriately called tendinosis?
You might be able to care for it a little better with the information above.
Read more like this in our Therapeutics Section of the Navina™ blog.
Last updated: September 2, 2018.
I actually have Tendinodis of my gluteus medius and minimus.. it was also treated as referred pain from a hernia disc in my back, there for I have been taking lyrica for 12 months as a result.
Sandy, this is sad to hear. I’m very sorry that this is happening! That is severe.
I hope you have some well-trained manual therapists to assist you!
As a side-note, and something your manual therapy team should know, is that disc herniations are actually mostly painless – it’s the surrounding trigger points that are almost always the cause of the pain associated with a herniation. They just need to locate the trigger points! Hopefully you and your wellness team can get on top of this pain soon.